UN political declaration on antimicrobial resistance signals high level recognition
New York, 26 September (Mirza Alas*) – On 21 September 2016 the United Nations General Assembly (UNGA) adopted the political declaration on antimicrobial resistance.
This is the 4th time in the history of the United Nations that a health topic has come to the attention of the UNGA.
The political declaration, which had been negotiated for several months, was approved by acclamation during the high level segment. Its adoption provides recognition of the critical nature of antimicrobial resistance (AMR) at the highest political level.
The declaration recognizes the World Health Organization (WHO) Global Action Plan on AMR as the blue print of action. It also acknowledges that the lack of access to health services and antimicrobial medicines continues to affect more people than resistance, and this constitutes a major challenge for developing countries.
The document clearly states that research and development efforts should be guided by need and by the principles of affordability, effectiveness, efficiency and equity as well as be de-linked from the price and volume of sales.
There are two calls for action in the text. The first one calls upon the WHO “together with Food and Agriculture Organization (FAO) of the United Nations and the World Organization for Animal Health (OIE), to finalize a global development and stewardship framework. ” Preliminary discussions on this framework have taken place in Geneva at the WHO Headquarters in early 2016 but this call for action gives an explicit mandate to continue the negotiations that will define and structure how this framework would look like.
The second call for action requests the Secretary-General to establish an ad hoc interagency coordination group co-chaired by the Executive Office of the Secretary-General and the WHO. During the negotiations for the political declaration civil society groups that were following the process in New York told Third World Network that it was necessary that the UN, with all its agencies, participated in creating actions within their mandates to complement and support the WHO leadership in this issue due to the fact that AMR is interconnected with many other aspects beyond human health.
During the opening segment of the high level meeting last week, that led to the adoption of the declaration, there were interventions by the President of the General Assembly, the Secretary-General of the UN, and the Directors-General of WHO, FAO and OIE respectively.
The President of the General Assembly Ambassador Peter Thomson (Fiji) emphasized the large impact that AMR will have and how it will affect the implementation of the Sustainable Development Goals, highlighting the importance of affordable and accessible medicines and vaccines.
UN Secretary-General Mr. Ban Ki-moon stressed the fundamental threat that AMR posses to human health, food production and development and how this could mean losing our ability to protect people and animals from infections, and putting the achievement of the Sustainable Development Goals in jeopardy. He further remarked that tackling AMR will require long-term commitments from everyone and coordination, cooperation and sustained financing. He further stressed that “commitments today must be turn into action.”
Dr. Margaret Chan, Director-General of WHO, reminded the audience that this is a global crisis that she referred to as a “slow motion tsunami” especially for the achievement of the Sustainable Development Goals. Dr. Chan explained that recently WHO had to update its treatment guidelines for syphilis, gonorrhea and chlamydia because of AMR.
She further emphasized that the emergence of resistance is out passing the world’s capacity to produce new antibiotics. Super bugs resistant to all available medicines haunt hospitals and intensive care units around the world. She also stressed that now is the time to see action and that the pharmaceutical industry is reluctant to invest in antibiotics and therefore incentives must be found.
Furthermore, Dr. Chan noted the important role that consumers play and how doctors need to stop prescribing unnecessarily and how they need better diagnostics and vaccines to prevent infections in the first place. She remarked on the importance of not using critical antibiotics for humans in animal husbandry.
Mr. José Graziano da Silva, Director-General of FAO, welcomed the political declaration and pointed out that it provided further guidance, particularly on the prudent use of antibiotics. He also noted that abuse, overuse and misuse have exacerbated the problem of resistance and that it is time to take responsibility to use antimicrobials in a sustainable way. He called for a phase-out of the use of antibiotics for growth promotion in livestock.
Dr. Monique Eloit, the Director-General of the World Organization for Animal Health (OIE), reminded the audience that this is the health threat of the century but that the situation is not inevitable, and that prudent use and good practices and alternatives do exist. She noted that research into new molecules has to be boosted and that there is a need for sustainable change in current practices as well as adequate legislation for control and distribution of antibiotics. Tools are needed for the One Health approach as well as strong and long-term commitment. Investment in health and veterinary systems is key, stressed Dr. Eloit. (One Health calls for actions that link the health of humans, animals and the environment.)
The High-Level Meeting then proceeded in two parallel sessions. One comprised of two panels with the participation of governments, civil society and industry while at the same time a parallel session took place where countries made their statements in support of the declaration.
The panel session was divided in two parts and had a moderator who directed questions to the participants so they each had a few minutes to respond. The first panel was on the relevance of addressing AMR for the achievement of the Sustainable Development Goals, in particular the health-related ones.
The first panelist was Ms. Veronika Skvortsova, Minister of Health Care of the Russian Federation. She emphasized the complex actions needed around AMR and the need for an inter-sectoral approach. She underlined that Russia has a national action plan that is based on inter-sectoral approach and which contains several targets including the reduction of the use of antibiotic in the food production chain and a federal law for state control on prescription of antibiotics.
The second panelist was Mr. Martin Khor, Executive Director of the South Centre. The moderator asked him what were his major concerns regarding AMR. Noting than resistance has spread to many diseases, Mr. Khor explained that vested interests have prevented the action that must be taken. He pointed out that this crisis will be more severe in developing countries where most cases will take place, and these countries do not have the money, the capacity, the diagnostics and the laboratories to face this crisis. Mr. Khor emphasized the need to make sure that developing countries have access to the antimicrobials that already exist and to the new ones.
The next panelist was Dr. Cleopa Mailu, Cabinet Secretary for Health of Kenya. Dr Mailu remarked that food security is a major concern and that AMR affects animal health, agriculture and human health and that this would have repercussions for food sufficiency. He further elaborated that AMR means easy eradication of gains in HIV, TB and Malaria. AMR with low investment in R&D means the possible resurgence of increasing mortality rates.
The following panelist was Mr. Vytenis Andriukaitis, European Union Commissioner for Health and Food Safety. Mr. Andriukaitis emphasized the need to ban antibiotics that are used for growth promotion. He underscored the importance of the One Health approach and the need to bring different actors together such as veterinarians, the pharmaceutical industry and environmentalists. In the case of the EU, growth promoters are banned. He also noted the need to see local and global actions and to have coordination and international cooperation.
The fifth panelist was Dr. Joanne Liu, the International President of Médecins Sans Frontières (MSF). The moderator asked about the role of MSF, and Dr. Liu pointed out that MSF is working in over 70 countries and fragile states and they are in the front line. She said that as a physician, “ I am running out of options to treat infections.” She provided the example of treating someone for war wounds but then later having the patient die of a bone infection. She stressed that AMR is a medical emergency and we need to get our mind into that, further noting that AMR should not be seen as a security threat but as a public health emergency, and public responsibility should be accepted for it.
The last panelist in the first round of the panel was Sir Andrew Witty, CEO of GlaxoSmithKline (GSK). He explained that there has not been a new class of antibiotics for decades and stressed the technical difficulties in finding new antibiotics. He said that GSK is working on a new compound and that they are moving to phase 3 clinical trials with good prospects. Sir Andrew also asserted that it was important to work together and highlighted the recent industry road map on tackling AMR, which includes conservation, and stopping pollution from production. He also spoke about exploring the de-linkage model and more sustainable methods of development.
Sir Andrew added that there are huge lessons to learn from the HIV AIDS crisis and there has been huge progress by getting 17 million people into treatment. He noted that there has been an advance in a new policy framework, for instance GSK is not longer asserting patents in low-income countries.
[A participant in the audience told TWN that the Least Developed Countries have an exception under the World Trade Organization agreement on intellectual property rights from granting pharmaceutical patents in their own countries until 2033.]
For the second section of the panel Ms. Skvortsova said that the discussion that had taken place was not a scientific one and that modern science was needed for intervening and changing the way microbes are being tackled.
The Kenyan minister stressed that the majority of deaths that will happen because of AMR will occur in developing countries and there is an urgent need to put in place national action plans to tackle this problem. He further underlined the importance to take steps for the implementation of the content of the declaration and the needs for developing countries to have surveillance, rapid diagnostic tests and vaccines. Dr. Mailu raised the need for creating awareness and education.
Mr. Khor of South Centre pointed out that the adoption of the declaration and the WHO Global Action Plan (2015) on AMR are good steps but he warned that this has happened before and that governments and international organizations have to step up and take leadership. He noted for example the Jaipur Declaration signed in 2011 with 18 action points but that the implementation has been slow. He stated, “ We don’t want a declaration with no action … this is as serious as climate change.”
Mr Khor asked about implementation about what are the barriers and how do we overcome this barriers. In the case of developing countries there are many competing priorities. Emphasizing the need to have leadership from the north to help the south to help themselves, he said that it is necessary to have implementation with resources, finance, technical equipment, ability to phase out and transition cost. A key issue that was highlighted during his intervention was the question of whether developing countries will have access to new antibiotics or will face issues such as in the case of the HIV epidemic and the treatment for hepatitis C where the prices have been so high that there is no access for many. Mr. Khor agreed that a delinking model is necessary but that it has to be linked to access to medicines and affordable prices.
Dr. Liufrom MSF stressed that there is an urgent need for action, and that the political declaration is not enough because there are many resolutions that have been passed and things have not changed much. She emphasized that it is critical that there is civil ownership to push the governments into action.
The last question of the moderator for the panel was about their role and the best way they could see for addressing the challenge.
Dr. Mailu, the minister from Kenya, explained that the stage is set. In the case of Kenya his role is providing the leadership as the Ministry of Health and to move forward with the national action plans and the multi-sectoral coordination.
Mr. Khor from the South Centre emphasized three things:
1. To reach out to governments in developing countries to convince them that this is a serious issue and help them to develop their national action plans,
2. To reach out to international organizations particularly the WHO and FAO to assist with the scientific data capacity, and
3. To empower civil society so they see this as an important issue, then it will resonate in society and the community. Civil society can tell politicians “this is what we want you to do.”
The message from the EU Commissioner for Health and Food Safetyreflected on the need to show leadership to build broader coalitions on public health issues, to coordinate on actions and provide guidelines and regulations, and to promote more viable and economical models for new antimicrobials. Mr. Andriukaitis also highlightedcooperation and implementation as well as obligations to act.
Ms. Skvortsova of the Russian Federation reaffirmed her commitment to work at the global, national and regional level and the duty to coordinate single inter-sectoral programs and work with all authorities as well as to provide assistance.
The GSK CEO said that they will continue to sustain innovation and reflected that what gets measured gets done. He provided the example of the Neglected Tropical Diseases initiative and how with clear targets it was possible to see who was going to deliver what.
Dr. Liu talked about the need to improve medical practices. Doctors want to do the right things but they need the right tools to do it, therefore access to vaccines, access to medicines that will treat our patients is critical. She also stressed the need to mobilize political support to get things done and ensure that physicians are part of the solutions.
Panel 2 was organized around addressing the multi-sectorial implications and implementation challenges of AMR.
The moderator asked the panellists about the ways to implementation and what works.
The first intervention was from Ms. Erna Solberg, Prime Minister of Norway, who spoke of the advantages of being a small country where people talk to each other and where media can play an important role in changing people´s attitudes. She gave the example of a TV Report on the use of antibiotics in chicken and how that impacted consumers who then demanded change, and then there was a policy response to eliminate antibiotics in chickens. Ms. Solberg called for an international ban on use of antibiotics as growth promoters. Another example that she mentioned was about fisheries in Norway and how industry developed a vaccine in response to the policy against use of antibiotics.
The second speaker was Dr. Jim Kim, the president of the World Bank, who highlighted the profound economic impact that AMR will have. He spoke on the importance of proper stewardship while also having access. Furthermore, he underscored how the underinvestment in health systems continues to be a problem and the need to look at incentives.
Mr. David George Velde, Board Member of the World Farmers’ Organization and Vice- President of the United Sates National Farmer´s Union spoke about producing basic food commodities and the processing chain before food arrives to ultimate consumers. Mr. Velde noted the important role of agricultural production to address AMR, to the extent there is public benefit to be gained. Producers also have concerns for their health and that of their families and there is need to avoid disproportionate burden on production aspects of food producers.
Dr. Paulyn Jean B. Rosell-Ubial, Secretary of the Department of Health of the Philippines pointed out that there is a need for international standards to follow. Local planning and implementation of these standards is most important.
Ms. Martha Tellado, the President and CEO of Consumer Reports, remarked that awareness and transparency are critical and there is urgent need to recognize that the basic common goal is public health. Implementation requires leadership of scale and we have not seen it. Norway has launched remarkable best practices but the question is how do these migrate to other countries. For example in the United States 80 percent of antibiotics are used to prevent animal diseases and in the farm; half of the world’s antibiotics are consumed by farm animals. In studies on food chains her organization conducted with responses from consumers and the market, 9 of 25 global chains pulled back on chicken with antibiotics, but only chicken and only in the US. She called for better information so consumers can make better choices.
Dr. Jorge Lemus, Minister of Heath of Argentina, spoke about the experience in his country where adequate legislation is required. Two challenges were raised. First, hospital infections have seen a significant growth of up to 12 percent where misuse of antibiotics and the lack of hospital control are key issues. Secondly, Argentina is a large chicken and beef producer and there is not enough surveillance and control yet. Argentina set up a national control agency in health and agriculture ministry. One of the serious problems is how to increase surveillance and action, particularly when it comes to resources in order to deliver real action. He further said that that as a big meat producer it is important for Argentina to have adequate control and international regulations are needed.
On the moderator’s question about how hospitals can be more transparent, Dr. Jim Kim responded that good surveillance and standard setting are needed. The World Bank is supporting Africa´s network of laboratories. There needs to be accountability by regulators and by patients coming to hospitals. Hospitals will have in their interest to publicize good performance in this area.
The representative from the World Farmers’ Organization responded to the questions about innovative ways, referring to an advertisement in the US showing poultry producers using herbs in water supply to help control disease. He also underscored that indiscriminate use in the livestock industry is driven by large agroindustry managing hundred of herds, as opposed to small family-run herds. He also said that the dynamics of the food industry of huge mergers and acquisitions, radically concentrating power in the food system, are driving managing practices that drive AMR.
The representative from Consumer Reports further noted that we have an opportunity that farm to table movements are becoming more popular, and that consumers want to be connected to food production and this is creating some reaction already.
Dr. Lemus from Argentina agreed that there is a need to empower the consumer but for this there is a need to have specialized informational campaigns. The Pan American Health Organization/WHO needs to create an expert movement to empower countries in these communication campaigns. If imports are controlled in third parties, exporting countries will respond to maintain market access. There is a need also to work with national agencies of evaluation of technology to guide the use of antibiotics.
The World Bank noted that we are not starting from scratch and that there has been work done already that can be used, for example on vaccines. Dr. Kim further emphasized the need to have targeted specific interventions of surveillance in the agriculture sector to understand what the patterns are of the use and lack of access in developing countries.
On conclusion of the panel session the second part of the day was dedicated to hear country statements. At the end of the evening the Chair read the official Communiqué that signaled the clear recognition of AMR as a serious threat to the entire world and to address it there is a need for multi-sectoral action. The following points were highlighted: Now it is time to get down to work. The Global Action Plan exists and countries have agreed to implement it. The need for innovation and education and sustainable financing in order to stop AMR as well as country level support are recognized. It will be critical that all actors adopt a long-term perspective. AMR is a global health issue that requires our urgent attention, and we need to build further political and public awareness. To enable us to achieve the SDGs it is clear that we do not have time to waste. The political declaration and Global Action Plan put in monition necessary steps to move forward to address the AMR challenge. It also recognized that there is a clear need to put words into actions and ensure a universal push to transform our world and that no one is left behind.
With these remarks the High Level Meeting on Antimicrobial Resistance was closed.
According to several civil society organizations that attended the panel, while the declaration is a good step and recognition at the highest level of this critical issue the declaration had few commitments on the mobilization of funds to support developing countries. It did not make specific commitments in the animal health sector. The declaration calls for a report back in 2018 at the UNGA and hopefully some of the commitments discussed in this meeting can be truly realized.
[*]With inputs from Viviana Muñoz of South Centre